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1、Hemodynamic optimization of sepsis-induced tissue hypoperfusionPresented by R2 柯維琦Supervised by V.S. 楊俊杰Review articleCritical Care 2006, 10(Suppl 3);S2本檔僅供內(nèi)部教學(xué)使用本檔僅供內(nèi)部教學(xué)使用檔案內(nèi)所使用之照片之版權(quán)仍屬於原期刊檔案內(nèi)所使用之照片之版權(quán)仍屬於原期刊公開使用時公開使用時, 須獲得原期刊之同意授權(quán)須獲得原期刊之同意授權(quán)IntroductionSevere sepsis and septic shockTissue hypoperfu

2、sion leads to multiple organ failureTimely clinical interventionPathophysiology, recognition and management of sepsis.End points Hemodynamic optimization Sepsis-induced tissue hypoperfusion Hypovolemic, cardiogenic and distributive shockSEPSIS to SEPTIC SHOCKEarlyCapillary leakVenous capacitanceCyto

3、kines releaseFluidtherapy EF and SV BPHRMaldistribution of BFCytotoxic hypoxia Septic shock v.s. Tissue HypoperfusionDefinitionSepsis with refractory hypotension SBP 90mmHg, MAP =40mmHg from baselineDespite fluid administrationTissue hypoperfusion Global Regional can present with NORMAL blood pressu

4、reHemodynamic monitoringIntensive care unitMonitoringlNoninvasive continuous ECG and pulse oxymetry Invasive monitoringlArterial pressure monitoringlCentral venous pressure (CVP), ScvO2 - normal 2-8 mmHg lPulmonary artery catheter (PAC), SvO2 - ongoing debate - intracardiac pressures, cardiac output

5、 (CO), mixed venous oxygen saturation(SvO2), pulmonary artery occlusion pressure (PAOP) Pulmonary artery occlusion pressure (PAOP) A reflection of left ventricular end-diastolic pressure (LVEDP)Strongly influenced by myocardial complianceMonitor in a dynamic waySvO2 CO, oxygen demand, hemoglobin, ar

6、terial oxygen saturation - Normal level: 70-75%Goals of Hemodynamic OptimizationRestoration of effective tissue perfusion and normalization of cellular metabolismGoals 1. Intravascular volume 2. Blood pressure 3. Cardiac outputGoal 1 - Intravascular volume HR 65mmHgU/O 0.5-1cc/kg per hrNon-invasiveI

7、nvasiveCVP 8-12 mmHgPAOP 12-15 mmHgSBP changes during positive pressure ventilationGoal 2 -Blood pressureBlood flow is regulated by auto-regulatory mechanism (MAP 60-120 mmHg)Target MAP 65mmHgPitfall chronic hypertensive patientsGoal 3 Cardiac outputMeasurements - thermodilution method by PACs - car

8、diac echocardiography - SvO2 or ScvO2Cardiac index (CI)= 3.0L/min/m2SvO2 = 65% or ScvO2 = 70%Surviving sepsis campaignSuriving Sepsis Campaign: sepsis resuscitation bundleEGDTTherapyFluid resuscitationBlood transfusionsVasopressorsInotropesFluid resuscitation Debate of type of fluid crystalloids (sa

9、line, Ringers acetate) colloids (albumin, hydroxyethyl starch) SAFE study (4% albumin, 0.9% saline) - no change in mortality, days spent in ICU or hospital, days with MV or renal replacement therapy Amount 20cc/kg crystalloids or equivalent colloids End points (CVP, MAP or CO)Blood transfusion Immun

10、osuppression or oxygen carrying ability of stored-blood Early-goal directed therapy (Hct 30%, ScvO2 = 65mmHgNOT exactly!Inotropes Myocardial dysfunction in sepsis - ventricular dilatation - decreased EF - impaired contractility Dobutamine, Epinephrine Dopaxemine dopamine analog with and dopamine agonist effect NOT rec